Based on medical record review, receiving hospital record review, staff interview, and policy review, the facility failed to ensure the receiving hospital accepted transfer for 1 of 1 sample patients (#2) who had an emergency medical condition and then experienced cardiac arrest. Refer to A2409 for details concerning facility failure to inform the accepting physician of the cardiac arrest and confirm the receiving facility agreed to accept the patient, whose condition had significantly changed and was no longer stable.

Based on medical record review, receiving hospital record review, staff interview, and policy review, the facility failed to ensure the receiving hospital accepted transfer for 1 of 1 sample patients (#2) who had an emergency medical condition and then experienced cardiac arrest. The findings were: Review of the emergency department (ED) record showed patient #2 was admitted on [DATE] at 11 AM with a complaint of fever and cough. The review showed the patient received a medical screening examination, and treatment which included lab tests and x-rays. Further review showed the ED physician contacted physician #1 at a local hospital on [DATE] at 12:20 PM and received acceptance to transfer the patient with a diagnosis of sepsis. Physician #1 was not the ED physician, and the plan was to admit the patient to the intensive care unit. The review showed EMS (emergency medical services) was contacted for transport. Review of the "Memorandum of Transfer" form showed the patient's risks were "worsening sepsis." The review showed the patient was stable for transfer via EMS and had vital signs which included a temperature of 98.8 degrees Fahrenheit, pulse of 144 beats per minute, respirations of 44, blood pressure of 92/54, and an oxygen saturation of 72%. The following concerns were identified: a. Further review of the ED record for patient #2 showed the patient had a significant change in status on 10/1/17 at 12:35 PM. At that time the respiratory therapist called the registered nurse to the patient's room. The assessment showed the patient was cyanotic and unresponsive, was not breathing, and had no pulse. By 12:40 PM the ED team had called a "code blue" and CPR (cardio-pulmonary resuscitation) was in progress. The code continued, and at 12:53 PM the physician was able to insert an endo-tracheal tube for assisted respirations. At 12:55 PM the team applied a Lucas device (device to perform mechanical compressions for the heart). PEA (pulseless electrical activity) was noted as the patient's heart rhythm at that time. At 1 PM a member of the arriving EMS team reinserted an endo-tracheal tube for assisted respirations. At 1:07 PM PEA was still noted. At 1:09 PM the patient was being transferred to the ambulance for transport and was noted to still be receiving mechanical compressions with the Lucas device. At 1:10 PM another pulse check was performed and the patient had no pulse. At 1:13 PM the ambulance left the facility parking lot with the patient. b. Review of the ED record showed the ED physician failed to document any contact with a physician #1 concerning the patient's change in status. The review showed the ED nurse contacted the receiving ED and gave report on 10/1/17 at 12:45 PM. Review of the "Memorandum of Transfer" form showed the facility failed to update the patient's risks from "worsening sepsis" to include cardiac and respiratory arrest. Further review of the "Memorandum of Transfer" form showed the facility failed to update the vital signs to reflect the status of no pulse, no respirations, and the patient being unresponsive. c. Review of the receiving hospital "ED Provider Note" dated 10/1/18 and not timed showed "after initial evaluation" the sending physician contacted physician #2 at the receiving facility ED and gave a report, which included the patient's code status. The note showed the patient was coded for 52 minutes at the receiving facility and the code was stopped "due to futility." Review of the entire receiving facility medical record showed no indication the sending ED physician had spoken to any physician at the receiving facility after the patient's significant change in status prior to transport. d. Interview with the sending ED physician by phone on 3/22/18 at 8:37 AM confirmed the transfer documentation had not been updated to reflect the patient's significant change in condition. He further confirmed he had failed to document any contact with physician #1 after the patient's change in condition, and could not remember if he had contacted her after the patient's significant change in status. e. Review of the facility "Emergency Services" policy titled, "EMTALA: Medical Screening Examination and Stabilizing Treatment," showed the following, "...B. Stabilizing Care. i. If the MSE demonstrates that an EMC (emergency medical condition) exists, [the facility] will provide Stabilizing Treatment within [the facility's] Capabilities, even if [the facility] must transfer the Patient....ii. A Patient with an EMC is stabilized when the physician/QMP (qualified medical practitioner) determines that: ...2. The Patient is stable for transfer (i.e., when the physician or QMP has determined, within reasonable clinical confidence, that the Patient is expected to leave [the facility] and be received at the second facility with no material deterioration of his/her medical condition and the treating physician reasonably believes the receiving facility has the Capability to manage the Patient's medical condition and any reasonably foreseeable complications of that condition)...H. Transfer requirements for the Patient: iv. Transfer of the Patient who is not Stable for Transfer is accomplished as follows: ...3. The Transfer is affected through appropriate means consisting of the necessary, qualified personnel and transportation equipment including the use of life support measures. In all cases a physician to physician conversation must occur prior to acceptance and initiation of the transfer process."

Based on interviews with staff, law enforcement, and DFS (Division of Family Services), and review of policies and procedures, police report, and event report, the facility failed to ensure a policy was developed to address a situation in which local law enforcement was called by the facility as an intervention for 1 of 1 confused family member. The findings were Refer to A2406 for details concerning facility failure to perform a Medical Screening Exam for a patient's family member who was in the waiting room and appeared confused. In addition, the facility lacked a policy for notification of law enforcement for this type of situation that did not include an unlawful act.

Based on interviews with staff, law enforcement, and DFS (Division of Family Services), and review of policies and procedures, police report, and event report, the facility failed to ensure a medical screening examination was completed for 1 of 1 family member who was confused and identified as needing continuous supervision due to cognitive impairment. In addition the facility failed to develop policies and procedures regarding notification of law enforcement; this failure resulted in the facility utilizing law enforcement to address the family member's condition; and medical and nursing interventions were lacking. The findings were: Review of the facility's Safety/Security Event Report, dated 11/6/17, showed a patient left a family member in the waiting room while s/he received surgery on 11/6/17 at 7:30 AM. Further review revealed the following information: the pre-operative nurse told admissions clerk #1 the family member had "Alzheimer's, so to look out for" him/her and s/he "was getting a ride from someone at some point". Admissions clerks #1 and #2 ..."looked out for [the family member] until 8:30 AM", when the family member asked admissions clerk #1 to call his/her "ride"; and later asked the admissions clerks to call the police take him/her home. The admissions clerks called the listed contact number on the patient's admission form 3 times and did not received a response. The family member had a pamphlet with a DFS case manager's name and number. The admissions clerks called the DFS case manager who told them she could not come to get the family member. The family member was adamant about leaving and "threatened to leave 3 more times" before the local law enforcement was called. The family member left the building and was redirected back to the waiting room area. At that time s/he was "pretty agitated." After a discussion between the officer and the emergency department (ED) manager, the officer transported the family member to the ED at another hospital. Interview on 1/2/18 at 11:30 AM with the DFS case manager revealed the following information: The patient's family member arrived at the patient's home from another state a few weeks prior to 11/6/17. The patient talked with the DFS case manager about finding placement for the family member due to severe dementia. The patient was scheduled to have surgery and inpatient admission on 11/6/17. At that time, the patient had not completed the required forms to receive assistance from DFS. On the day of surgery the patient arrived with the family member who had a small suitcase with him/her. At 6:45 AM the patient called the DFS case manager from the hospital and asked the DFS case manager to come to the hospital to pick up the family member. The DFS case manager told the patient this was not possible. Later, the DFS case manager received multiple calls from the hospital staff and each time she told them she could not come to get the family member. Staff told her, their facility could not keep the family member, and the DFS case manager repeated she was unable to do what they asked. Interview on 12/20/17 at 1:10 PM with the ED manager revealed the following information: The officer would not allow the facility more time to make additional contacts to get someone to come to get the family member. The ED manager told the officer the family member should be seen in the facility's ED, the officer said he was taking the family member to another hospital. After the officer departed with the family member the ED manager called the receiving hospital and told them about the family member who was enroute. The ED manager acknowledge the lack of documentation regarding the transport because the family member was not a patient and therefore no medical record had been developed. Interview on 12/20/17 at 1:20 PM with admissions clerk #1 revealed the family member was confused, not aggressive, and repeated,"Call the police they are supposed to come get me". Admissions clerk #2 further stated there were discussions about contacting someone to come to get the family member, but she was not aware of any discussions about having a physician examine the family member. Interview on 12/20/17 at 4:20 PM with admissions clerk #2 revealed she called the DFS case manager and was told DFS could not help because the patient had not followed through with the process for finding placement for the family member. Admissions clerk #2 stated she called law enforcement so they could come and take the family member home. She further stated the officer told her the expectation was to transport the family member to another hospital. Interview on 12/20/17 at 4:30 PM with admissions clerk #3 revealed the family member had a suitcase and was in the waiting area when admissions clerk #3 arrived at work at 9:30 AM. She further stated the officer was present; and the family member was confused and expressed a desire to go home. Interview on 12/21/17 at 12:50 AM with the pain management manager revealed when she arrived at the waiting area the admissions clerks were upset and weren't sure about what they should do. The pain management manager stated she called the ED manager and social worker; the admissions clerk had already called law enforcement. She stated the ED manager told the officer that this facility had an ED, but the officer stated he planned to take the family member to another hospital because that is what he usually did. Interview on 12/21/17 at 9:20 AM with the social worker/case manager revealed she talked with the family member in the waiting area and noted s/he was confused, smiling and talking about getting a ride home. The social worker/case manager further stated the officer told her he was called to come to get the family member. Interview on 12/21/17 at 10 AM with the maintenance technician revealed he received instructions from the admissions clerk to bring the family member back into the building when s/he went outside due to confusion. He further stated he asked the security staff to assist with monitoring the family member. Interview on 12/21/17 at 10:24 PM with the ED manager revealed he wasn't sure why law enforcement had been called. He stated the family member needed to be safe and keeping him/her in the waiting area for hours might not have been the safest place for him/her. He further stated notification of law enforcement could have been handled differently; and the facility needed to make changes in their process for addressing this type of situation. Interview on 12/21/17 at 8 PM with the law enforcement officer revealed the following information: He arrived at the facility on 11/6/17 at 9:20 AM. He was unable to get any information from the family member due to his/her confused state. The hospital administrative staff arrived and talked with him about issuing a legal hold. This was not an option because the family member was not a threat to self or others. The staff talked about other options, including the expense of keeping the family member at the facility, then told the officer there was nothing they could do for the family member. The officer was directed to transport the family member to another hospital. Review of the police report revealed the officer understood the facility wanted him to transport the family member to another hospital and he did. Review of the policies and procedures provided by the facility revealed none addressed a process, system, or guidelines for notification of law enforcement for lawful acts. Interview on 12/21/17 at 11:10 AM with the chief nursing officer revealed the patient did not tell the staff about the family member until the nurses were wheeling him/her into the operating room. She stated if staff had known prior to the day of surgery they could have helped the patient with placement for the family member. She verified a medical screening examination was not provided prior to law enforcement's arrival or afterwards. She stated the facility policies and procedures about notifying law enforcement specifically addressed reporting unlawful acts. However, she was unable to provide the surveyors with any policy and procedure or established guidelines for notification of law enforcement for lawful acts. Interview on 1/3/17 at 9 AM with the director of quality and regulatory at the receiving hospital revealed the family member arrived at the ED on 11/6/17 at 10:54 AM (this was over 4 hours after the family member arrived at the hospital with the patient). She further stated the family member was admitted after the medical screening examination was completed.